Psychological/Mental Health Need Special Housing

Request

You may request special housing if you have a qualified psychological/mental health condition. Housing & Residence Life works in conjunction with Furman’s Counseling Center and our on-campus medical professionals to ensure consistency in evaluating special housing requests. Only completed requests are reviewed. A completed request consists of this form, the Information from Health Care Provider (Psychological/Mental Health form, and the Authorization for Release of Information form.

A diagnosis must be made by a licensed mental health professional, such as a clinical social worker, a professional counselor, a psychologist, a psychiatrist, or a neurologist. Documentation must include the professional’s license number. The mental health care provider must not have significant personal ties to the student or the student’s relatives beyond the professional relationship.Requests and/or statements included in the medical documentation should not be interpreted as automatic approval for special housing.

DEADLINE FOR RETURNING STUDENTS: February 23, 2015
DEADLINE FOR NEW STUDENTS FALL 2015: June 5, 2015

INFORMATION TO BE COMPLETED BY STUDENT:

Date of Request:
*MM/DD/YYYY

When Accommodation is Needed:

Student Name:
*FirstLast

Furman Email Address:
*

Date of Birth:
*MM/DD/YYYY

Furman Student ID Number:

Phone Number
*###-###-####

In the space below, please detail your request, to include the type of housing, and the reason(s) for it:
*

NOTIFICATION OF APPROVAL/DENIAL WILL BE SENT TO THE STUDENT’S FURMAN UNIVERSITY E-MAIL ADDRESS. PLEASE MONITOR THAT E-MAIL FOR RESPONSE AND/OR REQUESTS FOR ADDITIONAL INFORMATION.